Seeing quorum, we will call our meeting to order. This is meeting number 67 of the Standing Committee on Health. We are doing our study on Bill C-45 on cannabis. Today our panel is focused on prevention, treatment, and low-risk use.

I welcome all of our guests who are here both by video conference and at the table.

As individuals, we have here today Michael DeVillaer, assistant professor and policy analyst at McMaster University, and by video conference, Mark Kleiman, professor of public policy at the Marron Institute of Urban Management at New York University.

Welcome.

From the Canadian Nurses Association, we have Dr. Lynda Balneaves, a registered nurse and medical and non-medical cannabis researcher, and Karey Shuhendler, policy adviser, policy advocacy and strategy. From the New Brunswick Medical Society, we have Dr. Serge Melanson, by video conference from Moncton. From the Nova Scotia Department of Health and Wellness, we have Dr. Robert Strang, chief medical officer of health, by video conference from Halifax.

Thanks very much. We'll start with 10-minute introductory remarks from each organization. Then we'll go to questions from the members.

Good morning, Mr. Chair, and members of the committee. My name is Karey Shuhendler. I'm a registered nurse and policy adviser for the Canadian Nurses Association, the national professional voice representing more than 139,000 registered nurses and nurse practitioners.

I'm pleased to be here today with Professor Lynda Balneaves, registered nurse and medical and non-medical cannabis researcher, who will be able to answer questions that are more technical in nature.

Professor Balneaves currently serves as an associate professor in the Rady faculty of health sciences college of nursing at the University of Manitoba, and is a nursing leader in the fields of shared treatment decision-making and complementary and integrative health care. She has published and presented on topics related to knowledge translation, integrative oncology, treatment decision-making, and medical and non-medical cannabis.

At the outset, I would like to thank the committee for studying this important issue and for inviting CNA to provide its recommendations. Legalization of non-medical cannabis will impact public health, and as such, requires a preventative approach to reduce the health risks and social harms associated with cannabis use. CNA welcomes the federal government's work to table Bill C-45, which would guide the legalization, regulation, and restriction of access for non-medical cannabis. CNA supports the passing of the bill and believes that legalization is an excellent option for addressing the harms of cannabis.

CNA recently conducted a national survey of nurses to assess the readiness for legalization, determine knowledge gaps and resources needed, and collect input on the sections of Bill C-45 that pertain to the scope of CNA's work.

While the two-month survey remains open until tomorrow, preliminary results indicate that a majority of nurse respondents favour the government's move toward legalization, and that the focus should be on preventing access and associated harms for young persons through a variety of mechanisms, including considerations around packaging, labelling, display, promotion, and sale of cannabis and cannabis accessories. Legalization can support the regulation of quality, dose, and potency, while minimizing social harms as well as the costs of prohibition. In addition, legalization can improve access to research potential harms or medical benefits.

In reviewing the bill, CNA was pleased with the moderate public health approach taken on the complex issue of cannabis legalization. In its current form, Bill C-45 promotes the removal of harms associated with the prohibition model, while recognizing the need to protect vulnerable populations, including youth. CNA has provided four recommendations for amending the proposed legislation, all of which are outlined in our brief. We encourage the committee to include all of CNA's recommendations in its final report, including those related to the sale and promotion of cannabis and cannabis accessories, and considerations around promotion and use related to alcohol.

Cannabis should not be treated in the same way as alcohol. The harms of alcohol use and current alcohol policy can be downplayed at times and should not necessarily serve as the model for cannabis policy simply because it is already established. Additionally, cannabis is different in that there are therapeutic indications and particular formulations for medical use. Thus, medical access should not be forgotten in the wake of legalization. While these other recommendations are not the focus of our presentation today, we would be pleased to answer any questions on the full range of recommendations put forth in our brief.

This morning we would like to focus on two of the four recommendations, namely, those related to youth criminal penalties and the inclusion of a comprehensive public health approach to the legalization of non-medical cannabis.

Our first recommendation, regarding youth criminal penalties, is specific to clause 8 and related subclauses. These state that a young person, aged 12 to 18, in possession of one or more classes of cannabis the total amount of which, as determined in accordance with schedule 3, is equivalent to more than five grams of dried cannabis, is guilty of an indictable offence, is liable and/or guilty of an offence punishable on summary conviction, and is liable to a youth sentence under the Youth Criminal Justice Act.

Not only can a criminal record limit an individual's ability to travel to certain countries, it can also lend itself to considerable social harms. For youth in particular, a criminal record can be a barrier to volunteer opportunities, which are often required by school curriculums, and can play a role in scholarship decisions. A criminal record can also reduce career opportunities and contribute to poverty and poor health outcomes. Legalizing cannabis while maintaining criminal penalties for youth can disproportionately disadvantage young people, particularly those from marginalized or racialized communities, potentially barring them from opportunities to equitably advance and contribute in our society.

Given the evidence that 21% of 15-year-olds to 19-year-olds in Canada have used cannabis in the past year, such legislation could potentially impact a large number of youths. Alternatives to a traditional punitive approach to addressing both minor crime as well as problematic substance use have demonstrated success. Examples such as drug courts, which use a restorative justice approach, offer an alternative to traditional justice processes. These models offer full engagement and accountability of the offender, and help to address the broader range of contributing issues such as poverty, health, or social justice issues that may have brought the person to commit the offence in the first place.

Consider a 15-year-old struggling with problematic cannabis use caught possessing more than five grams for personal use. He uses non-medical cannabis to self-medicate for undiagnosed anxiety and depression which is exacerbated by the stress associated with living in poverty. Would criminalizing possession or even imposing a significant fine help this teen, or would he be better served through a drug court system with a restorative approach, where the teen can be accountable in his own healing, provided with opportunities to link with health and social service organizations to address the root causes of poverty, and offered treatment services to address undiagnosed mental health and substance use issues?

With this in mind, CNA recommends that youth possession of cannabis not be subject to criminal penalties, that the government use a restorative justice approach as the guiding principle for addressing youth possession, and that such depenalization eliminate current or future repercussions for youth by removing the provision under clause 8 and related subclauses of the cannabis bill.

Our second recommendation is for the government's investment in a public health approach to cannabis, including a comprehensive public education program. CNA strongly supports the recommendations made to the federal task force on cannabis legalization and regulation to learn from other jurisdictions, such as Colorado and Washington, and to invest in comprehensive public health and education programs including those related to cannabis use while driving well in advance of legalization.

Canada spends more than one billion dollars annually to enforce cannabis possession laws, arresting about 60,000 Canadians for simple possession, and this accounts for about 3% of all arrests. Legalization should remove significant social harms as well as the financial costs associated with enforcement under the current model of prohibition.

With this in mind, CNA recommends that once legalization is in place, the government use a portion of the savings from enforcement and/or revenue from sales to invest in initiatives that contribute to positive health and social outcomes. Such investments should include tools, training, and guidelines to support public education programs for cannabis harm reduction strategies, programs for substance use prevention and treatment, and research to better understand the harms of non-medical use, as well as the potential benefits of medical use. Cost estimates for these measures can be derived from jurisdictions where cannabis has already been legalized, from public education campaigns that have been launched, and from current federal government investments in public education related to tobacco use.

Nurses are the largest group of health care providers in the country and are often a person's first point of contact with the health care system. As such, nurses are well positioned to contribute to the development and delivery of this kind of health education.

Results of a Nanos Research poll commissioned by CNA in August of this year, which will be tabled, note that more than nine out of 10 Canadians support or somewhat support nurses educating Canadians on the risks associated with non-medical cannabis use.

Preliminary results of CNA's national survey of nurses noted that 49% of respondents indicated that they felt comfortable initiating a conversation or responding to patient concerns about the risks associated with non-medical cannabis use. Based on these results, CNA is committed to providing additional educational resources on non-medical cannabis to support nurses caring for people across the continuum of care.

I would like to close by emphasizing that the legalization of cannabis is an excellent opportunity to reduce harms associated with non-medical cannabis use, but we must get this right. CNA encourages the committee to urge the federal government to incorporate all of the recommendations put forward by CNA.

Thank you and good morning. My name is Dr. Serge Melanson. I am the chief of staff and an emergency room physician at Moncton Hospital here in New Brunswick. I'm speaking today on behalf of the New Brunswick Medical Society, a professional association representing more than 1,600 physicians in New Brunswick.

As a professional association, we believe that we have a key role to play in advocating for improvements to health care delivery in New Brunswick. We have led the way in various initiatives, such as the promotion of team-based health care delivery. We have also been successful in promoting healthy living initiatives and policy changes to protect youth from health hazards such as smoking and the use of tanning beds.

We recently launched a campaign to make New Brunswick one of the top three healthiest provinces in the next 10 years. We've also collaborated with schools to improve healthy food choices, and we have promoted the mandatory use of ski helmets to prevent head trauma.

I would like to thank the House of Commons Standing Committee on Health for inviting me to speak today to the concerns of the New Brunswick Medical Society about the legalization of marijuana for recreational use.

In June this year, our organization published a position paper on the recreational use of marijuana, which included recommendations to the Government of New Brunswick on an appropriate framework to limit the harmful effects of marijuana use on New Brunswickers.

We also want to inform the public about the health issues associated with cannabis use, and we recently launched an information campaign for the public on marijuana use.

Like tobacco and alcohol, cannabis use can lead to negative health impacts. While Canadians will have the choice to consume marijuana legally in little less than a year from now, it is essential that they understand the risks. Making cannabis legal does not make it safe. We understand that the goal of the federal government in legalizing and strictly regulating cannabis is to decriminalize use of the drug and reduce illicit sales of the substance, but we believe there are still substantial concerns to address when it comes to the particulars of legalization.

Our position on legalization is in line with that of the Canadian Medical Association and their recommendations built on Canada's experience regulating alcohol and tobacco. We also support the guidelines developed by the Centre for Addiction and Mental Health for low-risk use of cannabis. One issue of particular concern to us in this discussion, from a prevention and low-risk use perspective, is the proposed minimum age for the legal possession and purchase of recreational marijuana. We believe very strongly that the proposed age of 18 under Bill C-45 sends the wrong message to young Canadians—that it is safe for them to consume marijuana at that age. There is clear scientific evidence that the brain of a young adult is still developing up to the age of 25 and that marijuana consumption can have adverse effects on brain development. While we would ideally like to see the legal age for recreational marijuana set at 25 in Canada, we recognize that this is not likely feasible and that 21 may be a more realistic age for the prevention of illicit purchase by young adults.

Over the past 14 years of practising emergency medicine in Moncton, I've seen first-hand a significant increase in the amount of cannabis use and its negative health effects in patients presenting to the emergency department, whether it be as the primary cause of their medical problem, something that is worsening an existing chronic disease, or something that may be unrelated to why they're there. I deal with the effects of cannabis use in the ER in a number of situations. These can be patients experiencing unexpected effects due to cannabis being laced with dangerous chemical additives, patients experiencing a cannabis-triggered issue called cyclical vomiting syndrome, cannabis triggering serious mental illness, and patients experiencing such serious health issues as chronic lung disease as a direct result of cannabis use.

I see patients who have consumed cannabis, adolescents and young adults, for the most part, who then go on to develop their first episode of psychosis, schizophrenia, bipolar disorder, and other significant mental health issues. Teens or young adults consuming cannabis will have a higher likelihood of developing these mental health issues if they continue to consume cannabis. Some young people may also be under the impression that these medical issues are curable. The reality is that these are lifelong diseases. Young Canadians are taking a significant risk in consuming cannabis. We believe there is a clear association between cannabis use and the onset of psychotic disorders, because the brains of these young adults are still in development.

Since we know that the recreational use of marijuana will be legalized and that increased use is likely to have an impact on health care, it is important that the provinces and territories have adequate resources to deal with it.

If Parliament adopts Bill C-45, the Government of Canada will be responsible for ensuring that the provinces and territories are adequately equipped to react to increased pressure on the health care system.

In addition, the Canadian government must ensure that the provinces and territories have the resources to adequately measure the impact of legislation to better adapt their awareness and education efforts to the situation, as well as their intervention and treatment services over time. Research on public health will be needed to measure the harmful effects of increased cannabis use on our communities and our citizens.

It is also critical that governments at all levels invest the necessary resources to support a strong and ongoing education and awareness campaign. If Canadians are to be presented with the choice to consume legal cannabis, they must have easy and clear information on the risks associated with making that choice.

In closing, I would like to make it clear that a decision by the Government of Canada to legalize the use of cannabis must be advised by these precautionary principles. Government has a fundamental responsibility to protect its population. It is of particular importance, on the legalization of cannabis, for government to ensure that it is living up to its responsibilities to all Canadians.

Thank you very much, Doctor. I just want to say that I live in Nova Scotia but I was treated for cancer at your hospital nine years ago, successfully so far anyway. I had great care, and I just want to say thank you for that.

Now, moving to the Nova Scotia Department of Health and Wellness, we have Dr. Robert Strang, chief medical officer of health, by video conference from Halifax.

Good morning to the committee, and thank you for the opportunity to speak to you today. I'm appearing on behalf of the chief medical officers of health for the 13 provinces and territories. I'm providing a collective public health perspective, not jurisdictional positions from any of the provinces and territories.

My remarks will be focused on this morning's topic of prevention, treatment, and low-risk use, but by necessity will touch base on other topics such as legal age, labelling, and packaging, which have been discussed in other sessions.

I have assumed that by prevention you mean the prevention of population and individual harm in relation to how cannabis is produced, distributed, retailed, and used, the prevention or at least the delaying of onset of use by those below the legal age, and the prevention of harm to populations that may be at increased risk.

Prevention is not just about providing information and education about risks and harms. Appropriate education and social marketing can be effective but only if they are part of a comprehensive strategy. Policy decisions related to how cannabis will be sold, how it will be priced, how it will be labelled and marketed, and the level of availability and accessibility are the most critical when it comes to preventing population harms, preventing harmful individual use, and minimizing underage use.

To be more specific, to have the strongest prevention approach, we make the following recommendations:

Cannabis should be distributed and sold through government monopolies where the primary objective is protecting public health and safety, and not revenue generation.

As recommended by the task force that advised the federal government, there should be no co-sale of cannabis with tobacco and alcohol products.

At the outset, price will need to be set to maximize purchase from the legal market, but over time, price needs to be used as a key tool in decreasing overall demand as well as encouraging consumption of lower-harm products, such as products with lower THC concentration and non-smokable forms.

Product promotion such as advertising, marketing, sponsorship, and product placement, including at the retail environment, needs to be prohibited at the federal level and complemented by similar provincial restrictions.

Product packages should be plain with clear and prominent warnings about risk.

At the retail level, prepackaged products such as cigarette-type joints should not be allowed as those can facilitate marketing, promotion, and glamorization of cannabis use.

The number, location, and density of retail locations, along with hours of operation, need to be carefully developed to balance access to legal products—and accounting for the current legislation's allowance of personal growing and online or mail order purchases—with prevention objectives.

Over the long term, a minimum age of 21 would be better than 18 or 19 at balancing between shifting young adults to legal supplies and decreasing use by those under age 18. I'm going to explain that recommendation a little more, because it is a key point that keeps coming up.

We know that one of the objectives is to move people from an illegal to a legal market. Certainly, setting age 19 or 18 will bring young adults into the legal market in the short term, but if one of our key objectives is to decrease use amongst youth who are under 18, and will always remain underage no matter if the age is 18, if they are using cannabis, they are going to have to access it from an illegal source. We know from clear evidence around tobacco and alcohol that setting an age of 21 versus 18 or 19 will, over time, have a greater impact on decreasing cannabis use rates and therefore keeping those individuals out of any market for cannabis for those under age 18. If one of our primary objectives is to have a set of circumstances that decreases use of cannabis by those who are underage, we are far better off with an age of 21 than of 19.

Moving along, public smoking and vaping of cannabis should, at a minimum, follow the current approach to public tobacco smoking and vaping, to prevent further normalization of cannabis smoking and re-normalization of smoking behaviours in general.

The approach to bringing edible and other concentrated and derivative products into the legal market needs to be done extremely carefully to minimize the normalization of cannabis consumption and protect children and youth. With respect to edible products, it must be made clear through legislative requirements that products that contain cannabis plant materials and extracts and active ingredients are not food products.

Since it is easier to loosen regulations than to tighten them, the initial regulatory approaches should err on the side of being more restrictive. Adjustments can be made as time progresses based on comprehensive monitoring and research. Such monitoring and research will need to be adequately resourced and established.

Programs that shape social and physical environments to support health and well-being in general, such as supporting healthy pregnancies, enhancing early childhood development, and ensuring adequate housing and income, are all important measures for primary prevention of problematic substance use in general and are and will be important in preventing problematic cannabis use.

Along with this submission, I'm pleased to attach a more detailed position paper from the provincial and territorial chief medical officers of health, as well as the Urban Public Health Network, who are the medical officers of health in urban centres. That more detailed report has been provided to the committee.

With respect to treatment, I do not have experience or expertise in the treatment of cannabis use disorders, but I would say that there are no treatment approaches or therapies that are specific to cannabis use disorder. There is a need for improving appropriate access to treatment of people with cannabis use disorder today as part of the need to improve treatment and access for people with a range of substance disorders. Whether the need for treatment will increase or decrease will really depend on decisions and the implementation of policies that I've discussed previously.

With respect to lower-risk use, an updated set of guidelines for lower-risk cannabis use, the development of which was led by Canadian experts, was publicly released in June of this year. Those guidelines have been endorsed in principle by the council of the chief medical officers of health. In summary, these guidelines recommend that the most effective way to decrease risk is to abstain; that the older one is when cannabis use is initiated the lower the risk of developing problematic use and adverse health effects over the lifetime. Higher THC concentration products have greater risks, so low THC concentrated products should be used. Synthetic cannabinoids, such as shatter, expose users to more acute and severe risk and should be avoided.

To protect lung health, routes of intake that involve smoking and combusted cannabis material should be avoided. Along with that, methods such as deep inhalation and breath holding that increase the psychoactive ingredient absorption also should be avoided. Frequent or intensive use has the highest risk of harm, so if people choose occasional use, one day a week or only on weekends is recommended. Avoiding driving while using alcohol and/or cannabis is extremely important.

Populations that are at higher risk from harm from cannabis and therefore should avoid use are pregnant women, people with a history or close family history of psychosis or substance use disorder. The combination of risk behaviours, such as early age of onset and frequent use, likely magnifies the risk. These low-risk cannabis use guidelines should form a key part of public awareness and educational initiatives related to cannabis legalization and should be incorporated in product labelling and should inform legalization policy decisions by all three levels of government.

With respect to Bill C-45, the provincial and territorial chief medical officers of health and Urban Public Health Network recommended in the paper I have provided that this initiative be guided by public health goals and objectives written into a statute. We were very pleased to see the public health orientation adopted by the federal government for this initiative and the explicit articulation of public health objectives as codified in the purpose section of the act, proposed section 7. We encourage provinces and territories to adopt similar public health orientation and include explicit articulation of similar objectives in their statutes.

Last, we suggest that the bill be amended to replace the word “illicit” with the word “illegal”. The term “illicit“ is stigmatizing in nature, and since stigma and discrimination reduction are important aspects of this initiative, we suggest avoiding using the term “illicit” whenever possible. We suggest using the term “illegal” instead, as it is a simple, clear, and unambiguous term that refers to the legal status of possession of the substance and it avoids the stigmatizing nature of the word “illicit”.

Thank you for your time and this opportunity. I look forward to our discussions.

Mr. Chairman, committee members, I bring to this presentation 40 years of experience in the prevention and treatment of drug problems. I've been a counsellor, a community developer, a teacher and a policy analyst. I think my interest is really in drug policy broadly defined to include alcohol, tobacco, pharmaceuticals, and it's within that context that I view this new drug industry we are establishing.

When we think about prevention of drug problems, we usually think of providing people with information to help them make informed decisions. Another necessary part of an effective drug prevention program is development of a regulatory framework for drug industry practices. This is a critical part of what we mean when we talk about strict regulation.

Alcohol, tobacco, pharmaceuticals, and cannabis are not ordinary commodities. Each year in Canada, alcohol and tobacco alone are associated with approximately 40,000 premature deaths, six and a half million days in hospital and a cost to the Canadian economy of over $30 billion. I want to emphasize that those are annual figures. The alcohol and tobacco crises have been with us for a long time, so long we don't think of them as crises. Despite our efforts at prevention and treatment, they persist year after year.

Recently a new drug epidemic has emerged. The opioid crisis began when a drug company aggressively launched a misleading advertising campaign for an opioid painkiller, oxycodone. The same company is now taking the same drug to the developing world with the same misleading information. During the campaign to legalize recreational cannabis, Canadians have received repeated assurances that this new industry will be strictly regulated, like other legal drug industries, and that this will provide the needed safeguards of the public's health.

A half century of international drug policy evidence tells us it is not so simple. Across our established legal drug industries, we see frequent failures in the striking of that important balance between industry revenue and protection of public health. The result is an enormous amount of harm that stresses our communities, families and treatment programs.

The state of the union is that we have three legal regulated drug industries and three public health crises. Early indications from the emerging legal cannabis industry suggest that it may be on a similar trajectory.

Perhaps it is time for a new approach. Many of the decisions in the development of legislation require the striking of that balance, sometimes a choice, between facilitating the success of a new drug industry and protecting public health. The logistics of cannabis legalization, as I'm sure everybody is realizing now, are incredibly complex. The stakes are high, outcomes uncertain, and caution is wise. Accordingly, I hope that the Standing Committee on Health will assign priority to the protection of public health and the prevention of harm.

I will provide four specific suggestions for doing so.

The first issue is a minimum legal age for cannabis use. Research shows that young people acquire their cannabis through their network of peer relationships. This is very important. The peer networks of young people, say 15- to 17-year-olds, are more likely to include 18- and 19-year-olds than they are to include 21-year-olds. Consequently, over the long term, a minimum age of 18 or 19 will, as we've heard, give easier access to cannabis for 15- to 17-year olds than will a minimum age of 21.

My first recommendation is that the government should choose public health protection over a larger legal market by setting a minimum age of 21.

The second issue is the importance of a full ban on advertising and other forms of product promotion. Research shows that advertising increases use of a drug and that increases in use of a drug are associated with increases in related problems. Advertising, even with strict limits, will increase cannabis use and related problems.

My second recommendation is that the government should choose public health protection over market growth by legislating a full ban on all forms of cannabis product promotion.

The third issue is the importance of a non-profit model or options for cannabis supply. We already have three legal, regulated, profit-driven drug industries which have not succeeded in protecting public health. We can reduce the risk of creating a fourth by removing the profit motive from cannabis sales. An essential difference is that a non-profit retail model would serve only the existing market, with no product promotion or product innovation intended to increase the size of that market.

My third recommendation is that the government should choose public health protection over market growth by restricting the retail of cannabis to a non-profit organization with public health governance.

The fourth issue is the importance of social justice for prevention and treatment. Between now and the widespread availability of legal recreational cannabis, which will require an amount of time well beyond July 2018, people are expected to continue to “just say no” to the use of recreational cannabis. It is unrealistic to expect that to happen. Charges for simple possession of cannabis amounted to well over 17,000 in 2016. Issuing of more criminal records will continue to have a devastating impact on the social determinants of health of these mostly young Canadians. Prohibition also poses a problem for those who are dependent on cannabis and are seeking treatment to improve their lives. In my experience as a counsellor, I never encountered a patient who was helped by a criminal record. It actually impeded their efforts.

My fourth recommendation is that the government should immediately decriminalize possession of small amounts of cannabis.

Mr. Chair, that concludes my prepared statement. Thank you again for this opportunity. I will do my best to address any questions committee members may have.

Mark KleimanProfessor of Public Policy, Marron Institute of Urban Management, New York University, As an Individual

Good morning, ladies and gentlemen.

It's a great honour to have been asked to address this distinguished body as part of this genuinely historic process. I've been working on cannabis policy for almost four decades now. My firm was the adviser to the Washington State Liquor Control Board as it implemented Washington's cannabis legalization.

I would urge you in this process to pay attention to results, not slogans. The case for the legalization of cannabis is not its lack of risk, as we've heard from the other witnesses this morning. The case for legalization is the inability to control the illicit market and the harm the illicit market does and the fact that lots of people would like to use cannabis and can, in fact, do so harmlessly.

There is a tendency in public policy debates and in policies themselves to lurch from one extreme to another. At least in the U.S., we're in the process of lurching from considering cannabis an evil weed to considering it a harmless herb. Unfortunately, each is an imprecise characterization.

For almost any drug, the majority of the users of that drug do so harmlessly, and indeed, with some benefit to themselves. That's what keeps them using it. A minority wind up losing control of their consumption and engaging in problematic use. Tobacco in the form of cigarettes is the one exception to that, where most of the users engage in problematic use.

That minority of heavy users, however, accounts for not only almost all the damage involved with the use of any drug but for a large majority of the consumption of that drug. I don't have the numbers for Canada, but in the U.S., more than half of all the alcohol consumed is consumed as part of drinking binges, even though most drinking occasions are not to intoxication and are harmless. Eighty per cent of the alcohol consumed in the U.S. is consumed by people who drink more than is good for them. We see comparable numbers with cannabis.

The goal of legalization, I suggest, ought to be the availability of cannabis to those who want to use it temperately while minimizing the number of people who get in trouble with it; so, access without excess. As we've heard from others this morning, that is not a goal that is automatically served by a free market, because that same 80-20 rule that drives public health concerns—as I said, 20% of the heaviest users are going to do themselves most of the damage—also drives marketing concerns.

If you are in the business of selling a drug that some people become addicted to, they are your best customers. What from a public health point of view is a diagnosis, from a marketing point of view is a target demographic. That's equally true whether you're British American Tobacco or Imperial Distillery or the Ontario liquor board. If your goal is to maximize the amount of money you make, you're going to focus on cultivating heavy users, and that's precisely the opposite of the public health objective we ought to be serving.

There's a widespread belief that we should regulate cannabis like alcohol, as if we've been successful in regulating alcohol. That seems to be an obvious fallacy once you have stated it. I think it would be wiser, if we're going to imitate some currently illicit market, to imitate the tobacco market, where, short of prohibition, the government makes aggressive efforts to minimize problematic use. That's a policy regime I've called grudging toleration. It seems to me that we ought to be grudgingly tolerating cannabis and not allowing its promotion.

A key element in promoting or controlling heavy use is price, again, as has been noted. It's important to understand that the natural tendency of the price of cannabis as a legal commodity is toward zero. A joint is a small amount of dried plant matter in a wrapping. The legal product that's closest to that is a tea bag. If we allow a free market in cannabis, the price of a joint will tend toward the price of a tea bag, and that's not where we want it to go. We already see in Colorado and Washington steady and rapid decreases in prices in the legal stores. My colleagues Jon Caulkins at Carnegie Mellon and Steve Davenport at RAND Corporation estimate that Colorado and Washington legal prices are falling at 2% per month and there's no bottom in sight.

The way to counteract that, if you're not going to have a public monopoly, is with aggressive taxation. That cannot be taxation based on retail price, because as the retail price goes to zero, the tax will go toward zero. The right way to tax cannabis, from a policy point of view and a health point of view, is to tax the active agent, THC. We need a specific excise, not an ad valorem tax. It should be substantial. Something like $50 a gram of THC would more or less maintain current illicit prices in the newly licit market, and that seems to me a reasonable objective.

Information is another key element of any prevention policy where we're trying to prevent a substance use disorder. Restricting marketing seems to me a very important idea, not merely because the advertising itself will attract new users, as it's intended to, but because the presence of advertising dollars will influence the editorial content of advertising media. It's striking that in the U.S., the first mass-market magazine to warn about the dangers of tobacco smoking was Reader's Digest. It wasn't because it was the most progressive or intellectually adventurous magazine; it was because it was the only one that was supported by reader subscription rather than by advertising. Controlling cannabis marketing will have a big impact on the way cannabis is described in editorial content.

Every cannabis buyer has to confront some seller, either somebody taking an order over the phone or a clerk in a store. That point-of-sale contact is the one place where we can make sure of connecting with every consumer. It seems to me that it would be wise to require those people to have training in pharmacology and in substance use prevention so that people, particularly new consumers, aren't getting their first information about cannabis from somebody who sells cannabis for a living and is frequently a very heavy user themselves. Those retail clerks ought to have a professional qualification and a professional obligation to give advice in the interests of the consumer and not in the interests of the store owner. They ought to be more like pharmacists than packaged goods clerks.

There are two things we might want to encourage both at that point-of-sale and in publicly funded information. One is the notion of use to less than intoxication. The striking difference between cannabis today and alcohol today is that most occasions of alcohol use are not to intoxication. That is not the case for cannabis. “Getting stoned” is a common synonym for cannabis use. It is possible that we might introduce to the population the notion that one might take a puff in order to improve the taste of food, or the sound of music, or the pleasure of conversation rather than having cannabis intoxication as the primary activity one is engaging in. I have no reason to think that this will work, but it's something we could try.

The other thing I'd like to see emphasized, both at point-of-sale and in mass media, is the importance of abstaining from combination use. Forty years ago in the U.S., cannabis on the one hand and alcohol and tobacco on the other were virtually opposites socially. They represented different cultural forces. Now in the surveys, heavy tobacco use, heavy alcohol use, and heavy cannabis use are all the same population.

Through cannabis legalization, one beneficial possibility is that you could substitute for other more dangerous drugs. We undertake policies to encourage that possible beneficial tendency.

I'm going to ask the question in French. You may want to use the earpieces if you need a translation.

Mr. Chair, I just participated in a town hall meeting last night in my region. More than 150 people came to get information. The facts are troubling. Before I tell you about it, I want to point out that I'm very impressed with the panel we have with us this morning. It includes experienced people from various areas of activity.

In my riding of Thérèse-De Blainville, north of Montreal, in the Lower Laurentians, 45% of youths 17 to 24 years of age admit to having used marijuana in the past year. The average for Quebec is 35%. In the case of youths 11 to 17 years of age, that percentage is 28%, while the average for Quebec is 24.9%.

Yesterday wasn't a cry of alarm, but I said it was urgent to act. This morning, that urgency is even stronger. With all due respect to my colleagues opposite, who want to delay things, it is clear that all the approaches that have been taken over the past 100 years have been a dismal failure in terms of preventing cannabis use among young people. The consequences, of which we are speaking at length, are serious. It has been pointed out in particular that the brain continues developing until the age of 25.

Yesterday, I was informed of some of the issues that you also raised. For me, the important issue isn't the money, but prevention and the health of our young people. But we are urging them to turn to the illicit market and organized crime. These aren't just dealers of cannabis, but of other drugs as well that we want our young people to experiment with even less.

The age issue concerns me. If it is decided that, for medical reasons, the required age should be 25, that isn't a problem. In fact, we all agree that using has consequences. However, we seem to be forgetting that, as of age 18, young people are given the responsibility of voting for representatives like us, who pass laws.

Are we going to tell them that they have the right to vote, but that they don't have enough social conscience to make an informed choice for their own health before the age of 21 or, in other cases, the age of 19 or 25?

I don't understand the logic of that.

Each province is independent in its choice of age. There is a difference between alcohol and cannabis, but are we going to do it for each product that will eventually be on the market?

That said, I would like to hear from the nurses. I quite enjoyed Mr. De Villaer's speech. I almost fully agreed with you, although a little less on the age issue. I would like to know a bit more about these kinds of issues. In terms of the market price, on the street, we were talking yesterday about $20 for 3.5 grams. Price is an important factor. If we offer prices that aren't consistent with the market, we won't change anything.

I have used up four minutes, but I can tell you that the last night was very informative.

I would like to hear your comments on the age issue, the logic around it and the related consequences.

The Canadian Nurses Association approaches the question of age from a harm reduction perspective. For all of the things that have been discussed over multiple days, as we've been hearing, we feel that they need to be very carefully balanced.

We do recognize that brain development continues to occur until age 25, according to the research, and that there are harms associated with cannabis use, but as we've heard just now and throughout the preceding days, we recognize that setting an age too high could continue to leave the people in Canada who use cannabis the most at highest risk from the harms of the illicit market. That includes the crime associated with purchasing in an illegal market and the harms associated with an unregulated product when you don't know the potency or the safety of what's in there.

Instead of on the age itself, we really think that the emphasis needs to be on educating all members of the population, especially vulnerable people or, potentially, the highest users, by developing education and involving all stakeholders so that you can have a conversation with youth, it's not a paternalistic approach, and they know of the harms and can make an informed decision.

I'll just add to that. It's well established—the stats are well known—that Canada's youth are among the most prevalent users of cannabis around the world. By raising the age, we're potentially still keeping our cannabis use a very “hidden in the shadows” health behaviour. We need to have youth being able to go to health professionals and to talk about their use, to talk about the problems associated with it, and to receive the appropriate education and the referrals to harm reduction programs in order to address problematic use.

We also need to be able to open the dialogue with our youth about the potential harms, many that they may not be aware of. We've seen research that suggests many youth begin to use cannabis in social settings. They see it as almost a social lubricant. They don't associate harms with it. They may not be aware of what the long-term harms are that are related to career and educational attainment, as well as the cognitive development issues and the mental health issues that have been raised by other panellists today.

We need to make sure that we're opening that dialogue and being respectful of youth's ability to make decisions around their health care behaviour.

The only point I would add is that there's something I've found we hear a lot and I find a bit strange. We frequently hear the comment that it's easier for young people to get cannabis than alcohol and tobacco. The reality is that the studies say exactly the opposite.

Specifically, I'm talking about the Ontario drug use and health surveys that the Centre for Addiction and Mental Health does now. They've been doing these surveys for 40 years. They know what they're doing with this. Their data show that underage people report that it's easier for them to get alcohol and tobacco than it is to get cannabis. The reason is that their peers of legal age are their suppliers. In other words, if you're 18, you can get alcohol and tobacco from your 19-year-old peers, but your 19-year-old peers don't have legal access to cannabis, so it's not so easy.

I think this is an important part. We really need to look at the data when we hear comments that get people excited and worried. I'll leave it at that.

I agree with what my colleague across the way has said, which is that young people are smoking cannabis. Whether it's legal or illegal, they're smoking it, so we certainly shouldn't be in a rush to worry about whether it's legal or not. What we should be doing is trying to prevent harm.

We've heard over three days this week a consistent message that the key to getting young people to not smoke cannabis is public education, public awareness, and training for them similar to the effort that was done with tobacco, to change public opinion to “grudgingly tolerating”. I liked that phraseology. That is definitely what's needed.

In the two years since the Liberal government announced they were going to legalize cannabis, that public awareness campaign has not appeared. Certainly, that's something that needs to be a priority, but we did see pockets of excellence. We had testimony yesterday from individuals who have brought forward training for parents.

I understand, Dr. Melanson from New Brunswick, that you did some public awareness training. I was wondering if you could expand on what your experience has been in Moncton.

Essentially, my first-hand experience as an emergency physician for the past 14 years has been recognizing an exponential increase in the usage of cannabis in patients presenting to the emergency department.

Really highlighting your point on public awareness, one of the things I brought up in my address earlier was this concept of a medical condition that's only now starting to become recognized and studied. It's referred to as cannabinoid hyperemesis syndrome or cyclical vomiting syndrome. This is a condition where mostly young people, young adults, will present themselves to the ER department after days of uncontrollable vomiting, not knowing themselves what the cause might be. After an extensive panel of medical tests are conducted and we conclude that there is nothing medically or organically wrong with them, we then begin questioning them a bit more thoroughly on their use of cannabis and discover, quite often, that they are using cannabis on a fairly regular basis. They themselves often believe that they are well-informed in regard to the harms of this drug. When we educate them on the likely association of their cannabis use and the cyclical vomiting syndrome, they're often quite surprised. When we provide them with additional information and counselling on how to abstain from cannabis use, we often see this debilitating condition essentially disappear.

I think that speaks very much to your point that, as much as people may believe they are aware of the health risks associated with cannabis, there needs to be a more focused effort on providing more relevant and important information to the consumers of this drug.

Picking up on one of your points, I would say that potency has been raised as a big concern. The cannabis of today is much more potent than previously. I think it was the nurses society that said it wanted to see really good control over the quality, the dose, and the potency that people are getting.

Another way of protecting the public from things that are not well controlled is to get rid of one of the suggestions that's in Bill C-45, which is to allow home growth. Home growth has absolutely no quality control on the product, on the potency, on any of these things, and also provides easier access for children.

I wonder if the Canadian Nurses Association would like to start, and then we'll let everyone comment on whether they think allowing home growth is a good idea.

The risks posed by homegrown cannabis mirror some of the risks that we have associated with access to alcohol, tobacco, and pharmaceutical drugs in the home. Again, it really points to the need for public education related to the potential harms of cannabis, particularly to children who may consume it unaware of those risks.

It really points to the need for regulation around self-produced cannabis in terms of the source plants or seeds that will be used as a way of limiting potency, limiting the number of plants and plant material that is available within the home, and ensuring that there's regulation related to storage, labelling, and the use of that product in an edible form that may be, again, more attractive to children.

We support regulations related to safe storage and production. Again, it supports the need for open and non-judgmental conversation between parents and children about what cannabis is, how it can be used safely, and why there are restrictions around use in people who are under the age of 18.

I was really interested to hear about the statistics on what alcohol and tobacco cost us: 40,000 deaths, 6.5 million hospital days, and $30 billion annually. The conversation that we've been having is that we should legalize marijuana and treat it similarly to how alcohol and tobacco have been treated. However, this brings to mind that perhaps those things aren't a success, so perhaps we shouldn't be trying to mirror what was done there. Perhaps we should learn from those, and consider a raised age.

One thing I would like to expand on is this idea of the non-profit-driven supply. We heard this yesterday from our friends from Quebec.

I think it was you, Dr. DeVillaer. How would that work in Canada? What do you think that would look like?

One of the popular models—and the group from Quebec, I think, is very much in favour of this—is something that is found in a number of European countries where they have small co-ops. These are user-run co-ops that pay their staff salaries, but there is no motive to expand membership in any way, no motive to get the current members to use more of the product, and these are key ways of preventing this from becoming a problem.

I think people are familiar with co-ops. There are a lot of people in communities who will join a co-op to get vegetables and so forth. It's really an extension of that very simple concept.

The important thing I think it brings is.... All you want to do is simply serve the existing market and not expand it. What we know from decades of research around alcohol and tobacco is that the more you promote a drug through advertising, the more it's used, and the easier you make access, the more it's used. That's how you expand a market. The problem here is that as the market expands, so does the number of people who have related problems. That's why market expansion is important.

The only other point I'll make very quickly is that, again, we have had a very difficult time internationally, not just here in Canada, of regulating our legal drug industries in a way that they achieve that balance of industry revenue and protection of public health. It's much more difficult than most people think.